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International guidelines recommend intrapartum cardiotocograph (CTG) monitoring for women at risk for poor perinatal outcome. Research has not previously addressed how midwives and obstetricians enable or hinder women's decision-making regarding intrapartum fetal monitoring and how this work is structured by external organising factors.To examine impacts of policy and research texts on midwives' and obstetricians' work with labouring women related to intrapartum fetal monitoring decision-making.We used a critical feminist qualitative methodology known as Institutional Ethnography (IE). The research was conducted in an Australian tertiary maternity service. Data collection included interviews, observation, and texts relating to midwives' and obstetricians' work with the fetal monitoring system. Textual mapping was used to explain how midwives' and obstetricians' work was organised to happen the way it was.CTG monitoring was initiated predominantly by midwives applying mandatory policy. Midwives described reluctance to inform labouring women that they had a choice of fetal monitoring method. Discursive approaches used in a national fetal surveillance guideline, a Cochrane systematic review, and the largest randomised controlled trial regarding CTG monitoring in labour generated and reproduced assumptions that clinicians, not labouring women, were the appropriate decision-maker regarding fetal monitoring in labour.Guidelines structured midwives' and obstetricians' work in a manner that undermined women's participation in decisions about fetal monitoring method. Intrapartum fetal monitoring guidelines should be critically reviewed to ensure they encourage and enable midwives and obstetricians to support women to make decisions about intrapartum care.

Refereed/Peer-reviewed Background: Integral to quality midwifery practice is the education of midwives. Like other countries, Australia faces ongoing challenges in delivering midwifery education programs. Reasons include escalating program costs, challenges in securing meaningful clinical experiences, subsumption of midwifery with nursing, and associated loss of identity in some institutions. Aim: To critically examine the literature exploring the historical and current drivers, supports and impediments for entry-to-practice midwifery programs to identify strategies to strengthen midwifery education in Australia. Methods: A structured integrative literature review using Whittemore and Knafl’s five-stage framework was undertaken; 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation of results. Findings: The literature search identified 50 articles for inclusion. The thematic analysis identified four key themes: i. a commitment to educational reform, ii. building a midwifery workforce, iii. quality maternity care through midwifery education, and iv. progressing excellence in midwifery education. Discussion: Extensive literature describes the evolution of midwifery education in Australia over the last 30 years. Through collaboration and amidst opposition, quality midwifery education has been established in Australia. Identification of midwifery as a distinct profession and transformative leadership have been integral to this evolution and must be grown and sustained to prevent a decline in standards or quality. Conclusion: There is a need to address priorities in midwifery education and for the evaluation of midwifery programs and pedagogy. The provision and maintenance of quality education and practice require shared responsibility between education providers and health care services.

Problem Little is known about what midwifery leaders need to effectively contribute to maternity services reform. Background Despite evidence establishing midwifery continuity of care as the gold standard of maternity care, implementation of these models has been slow. Midwives in health service leadership roles are in an ideal position to re-orientate maternity services to midwifery continuity of care. Question What do midwives in leadership positions need in order to be effective in contributing to the reform of maternity services in Australia? Methods This qualitative descriptive study used purposive sampling to recruit 13 midwifery leaders from across Australia. Individual telephone interviews were conducted and analysed through line-by-line coding and identification of themes. Findings Five main themes emerged from the data: ‘core leadership skills and education are essential’; ‘motivation and commitment to implementing evidence-based maternity care’; ‘ability to create and sustain strategic relationships’; ‘bringing the vision to life’ which contained two sub-themes of ‘changing the culture’ and ‘reaching midwifery’s full potential’; and, ‘organisational support and commitment are key to maternity reform’. Discussion This study echoes findings from previous research emphasising the importance of leadership attributes and development opportunities for midwifery leaders. Additional needs of midwifery leaders were also revealed, which have not yet been extensively explored in the literature, including a strong commitment to continuity of care, effective relationships with key stakeholders and support from healthcare executives. Conclusion Midwifery leaders need to be equipped to contribute to maternity care reform through leadership development opportunities, effective relationships and support from healthcare executives.

Aim To investigate the prevalence of burnout, depression, anxiety and stress of Lithuanian midwives. Design A descriptive, cross-sectional survey design. Methods The Work Health and Emotional Wellbeing of Midwives (WHELM) survey instrument developed within the Australian maternity context was adapted and used in this research. The survey collects country-specific demographic data and incorporates several validated measures including the Copenhagen Burnout Inventory (CBI), Depression, Anxiety and Stress Scale (DASS-21). Results Three hundred and thirty-eight completed surveys were received. Results obtained using a CBI subscale showed that 84.9% experienced personal burnout, 70.1% reported work-related burnout and 41.1% had client-related burnout. The results indicate that the midwives reported moderate to extreme levels of depression (16.3%), anxiety (28.4%) and stress (13.9%) symptoms.

Problem In countries where education programmes are assessed as meeting international standards there is limited knowledge about the challenges facing midwifery education. Background/aim The positive impact of quality midwifery education on maternal and newborn health is acknowledged by the World Health Organisation. However, there is limited research identifying the issues faced in providing quality midwifery education. The aim of this study was to identify the challenges and determine priority projects to strengthen midwifery education across Australia and New Zealand. Methods A two-round Delphi study with experts in midwifery education was undertaken. Findings In round one, 85 participants identified an initial 366 issues for midwifery education. Through thematic content analysis these were categorised into 89 statements reflecting five major themes: In round two, 105 midwifery experts from Australia n = 86 (79%) and New Zealand n = 23 (21%) rated the 89 statements in order of priority. Across the combined data (Australia and New Zealand) a total of 19 statements gained consensus of ≥80%. Discussion Five priority themes were identified including; (1) enabling success of First Peoples/Māori midwifery students; (2) increasing the visibility and influence of midwifery within regulation, accreditation and university governance; (3) determining how best to deliver the clinical practicum component of programmes; (4) reviewing midwifery programmes to enhance design, content and delivery; and (5) ongoing education and support for the midwifery workforce. Conclusion In Australia and New Zealand, it is imperative that collaborative work is undertaken to design and action identified projects addressing these priorities.

Problem Ensuring an adequate supply of the midwife workforce will be essential to meet the future demands for maternity care within Australia. Background Aim: To project the overall number of midwives registered with the Nursing and Midwifery Board of Australia and the timing of their retirement to 2043 based upon the ageing of the population. Methods: Using data on the number of registered midwives released by the Nursing and Midwifery Board of Australia we calculated the five-year cumulative attrition rate of each five-year age group. This attrition rate was then utilized to estimate the number of midwives registered in each five-year time period from 2018 to 2043. We then estimated the number of midwives that would be registered after also accounting for stated retirement intentions. Findings Between 2018 and 2023 the overall number of registered midwives will decline from 28,087 to 26,642. After this time there is expected to be growth in the total number, reaching 28,392 in 2028 and 55,747 in 2043. If midwives did relinquish their registration at a rate indicated in previous workforce satisfaction surveys, the overall number of registered midwives would decline to 19,422 in 2023, and remain below 2018 levels until 2038. Discussion Due to the age distribution of the current registered midwifery workforce the imminent retirement of a large proportion of the workforce will see a decline in the number of registered midwives in the coming years. Additional retirement due to workforce dis-satisfaction may exacerbate this shortfall.

Graduating midwives unsuccessful in gaining employment in their preferred model/location; or finding a job within a year of graduation are more likely to leave the profession. Obtaining post-graduate midwifery employment is competitive with midwifery students needing to confidently sell themselves to potential employers. Whilst midwifery students may be prepared with the requisite midwifery skills and knowledge, there is no guarantee of attaining a midwifery position upon graduation. Increasingly employers are requiring 'soft skills' including communication, teamwork, reflexivity and personal attributes of the individual to be able to effectively respond within different contexts. Demonstrating these skills within an employment interview requires confidence and knowledge in how to prepare. Designed with health service partners, simulated employment interviews were introduced into the final year of a Bachelor of Midwifery program as part of a suite of employability strategies connected to the student lifecycle. An exploratory evaluation study of students 'experiences of a simulated employment interview was undertaken. The simulated interview emulated real employment interviews with students receiving immediate written and oral feedback. Evaluation through surveys, focus groups and individual interviews provided rich data around the effectiveness of this approach. Students, health service partners and academics found the simulated employment interview provided a valuable learning experience, assisting students to reflect, explore and further develop skills sought by employers. Collaboration with health service partners created an authentic process enabling students to receive feedback relevant to the real world of practice. Students were able to work through anxiety, gain confidence and exposure to employers in preparation for employment interviews.

Currently there is no discipline-specific definition of critical thinking in midwifery practice.Critical thinking in midwifery practice is the cornerstone for safe, evidence based, and woman centred clinical decision-making. Available definitions of critical thinking in other disciplines do not align with midwifery practice which is distinctive, multidimensional and complex.To develop an international consensus definition of critical thinking in midwifery practice.A two round Delphi study was used. Thirty-two international midwifery experts contributed to the first round which was qualitative in nature. Twenty one of these experts then ranked the relevance and clarity of concepts from round one.A consensus definition of critical thinking in midwifery practice was achieved. The expert panel identified and defined 14 'Habits of Mind' and 12 Skills that are the core of critical thinking in midwifery practice. Skills included; analysis, constructive application and contextualisation of best available evidence, problem solving, discriminating, predicting, evaluation of care, collect and interpret clinical cues, collaboration/ negotiation, reflexivity, facilitates shared decision-making, communication, and transforming knowledge. Habits of Mind included; intellectual curiosity, reflective, holistic view, intellectual integrity, flexibility, questioning/challenging, participatory, open mindedness, listening with understanding and empathy, cultural humility, woman centred, being brave, confidence, and creativity.This study is an international first and delineates characteristics of critical thinking in midwifery. Development of a consensus definition provides a common and shared understanding of the skills and attributes required for critical thinking in midwifery practice and can also be applied in education and research.

Background Continuity of midwifery care is the best maternity care model for women at any risk level, and there is a global imperative to improve access to midwifery-led care. However, diverse perspectives about how best to prepare graduates for working in midwifery continuity of care models persist. The continuity of care experience standard in Australia was anticipated to address this. Aim To challenge the dearth of published information about the structures and processes in midwifery education programs by identifying: the educational value and pedagogical intent of the continuity of care experience; issues with the implementation, completion and assessment of learning associated with continuity of care experience; and discuss curriculum models that facilitate optimal learning outcomes associated with this experience. We discuss the primacy of continuity of care experience in midwifery education programs in Australia. Discussion The inclusion of continuity of care experience in midwifery programs in Australia became mandatory in 2010 requiring 20, however this number was reduced to 10 in 2014. Research has shown the beneficial outcomes of continuity of care experience to both students and women. Continuity of care experience builds mutual support and nurturing between women and students, fosters clinical confidence, resilience, and influences career goals. We require curriculum coherence with both structural and conceptual elements focusing on continuity of care experience. Implications and recommendations Education standards that preference continuity of care experience as the optimal clinical education model with measurable learning outcomes, and alignment to a whole of program philosophy and program learning outcomes is required.

Background Work integrated learning opportunities account for approximately half of the Bachelor of Midwifery program with the goal being to ensure that on graduation students are skilled to provide woman centred evidenced based midwifery care within any environment. There is increasing concern, however, over the quality of clinical experiences students are afforded. Objective This study explored the experiences of third year Bachelor of Midwifery students in South East Queensland undertaking a clinical placement within a midwifery caseload model. Design A qualitative descriptive approach was adopted. Data were collected using semi-structured, digitally recorded telephone interviews. Thematic analysis was used to analyse the data set. Setting Midwifery student clinical placement in caseload practice Participants Twelve third year Bachelor of Midwifery students from one university who had experienced a clinical placement in a caseload midwifery model of between 4 and 8 weeks. Findings Five themes emerged. These were labelled ‘stepping in her shoes’, ‘bringing it all together’, ‘my own captive educator’, ‘knowing the woman’, and ‘it was hard – but it was worth it’. The three-way relationship between midwife, woman and student facilitated deep and active learning leading to a growth in confidence and readiness for practice. Students were afforded the opportunity to constantly integrate theory into practice within a woman centred social model of care where they also grew to understand how midwives operationalise caseload practice in a sustainable way. Students acknowledged the challenges they faced undertaking the placement, but all confirmed the value it had afforded them. Key conclusions and implications for practice This study has provided evidence that situating midwifery students within a continuity of care model facilitated a rich holistic learning experience for students. Not only did the placement enhance student's confidence and competence it also provided a real-world view of what working in that a caseload model could be like on graduation. This is vital if the profession is to support system level change ensuring all women have access to evidence informed maternity care.

Background Internationally, midwifery education and maternity services are evolving to promote midwifery continuity of care. It is unclear whether current Australian midwifery education programs are graduating a midwifery workforce prepared and motivated to work in this way. Aim To discover how well midwifery students in Australia feel they have been prepared and motivated to work in midwifery continuity of care when they enter practice. Methods A pragmatist approach was used. Participants were final year midwifery students at one Australian university participating in the Midwifery Student Evaluation of Practice (MidSTEP) project over three consecutive years. Descriptive analysis of selected scaled and free text responses was undertaken to ascertain how students’ clinical practice experiences had influenced their learning, development and career aspirations. Results Exposure to midwifery continuity of care had profound impact on students’ learning, enabling them to provide woman-centred midwifery care whilst increasing confidence and preparedness for practice. The majority were motivated to work in midwifery continuity of care upon graduation. A small minority of participants felt unprepared to work in midwifery continuity of care, attributing this to their family commitments, a sense of needing more experience or unsupportive workplace cultures. Summary Midwifery continuity of care experiences are highly valued by midwifery students and positively influence confidence, preparation and motivation for beginning practice. It is necessary to review education standards to ensure quality, consistency, and adequacy of these experiences throughout pre-registration midwifery education. This will assist in generating a midwifery workforce prepared and motivated to deliver the goals of maternity service reform.

Background Central fetal monitoring systems transmit cardiotocograph data to a central site in a maternity service. Despite a paucity of evidence of safety, the installation of central fetal monitoring systems is common. Aim This qualitative research sought to explore whether, and how, clinicians modified their clinical safety related behaviours following the introduction of a central monitoring system. Methods An Institutional Ethnographic enquiry was conducted at an Australian hospital where a central fetal monitoring system had been installed in 2016. Informants (n = 50) were midwifery and obstetric staff. Data collection consisted of interviews and observations that were analysed to understand whether and how clinicians modified their clinical safety related behaviours. Findings The introduction of the central monitoring system was associated with clinical decision making without complete clinical information. Midwives’ work was disrupted. Higher levels of anxiety were described for midwives and birthing women. Midwives reported higher rates of intervention in response to the visibility of the cardiotocograph at the central monitoring station. Midwives described a shift in focus away from the birthing woman towards documenting in the central monitoring system. Discussion The introduction of central fetal monitoring prompted new behaviours among midwifery and obstetric staff that may potentially undermine clinical safety. Conclusion This research raises concerns that central fetal monitoring systems may not promote safe intrapartum care. We argue that research examining the safety of central fetal monitoring systems is required.

Objective Technologies for fetal heart rate monitoring have been widely introduced despite evidence of no improvement in perinatal outcomes. A significant body of research has raised concerns that healthcare information technologies can have unintended consequences. We sought to describe an unintended consequence of central fetal monitoring technology. Design The research was conducted as an Institutional Ethnography. Data generated from interviews, focus groups, and observations were analysed to generate an account of midwives’ experiences with the central fetal monitoring system. Setting The birthing unit of one Australian maternity service with a central fetal monitoring system. Informants 34 midwives and midwifery students who worked with the central fetal monitoring system. Findings Midwives described a disruptive social event they named being K2ed. Clinicians responded to perceived cardiotocograph abnormalities by entering the birth room despite the midwife not having requested assistance. Being K2ed disrupted midwives’ clinical work and generated anxiety. Clinical communication was undermined, and midwives altered their clinical practice. Midwives performed additional documentation work to attempt to avoid being K2ed. Key conclusions This is the first report of an unintended consequence relating to central fetal monitoring, demonstrating how central fetal monitoring technology potentially undermines safety by impacting on clinical and relational processes and outcomes in maternity care. Implications for practice Current evidence does not support implementation or ongoing use of central fetal monitoring systems. Further research is needed to inform scaling down central fetal monitoring systems in a safe and supported way.

Highlights: Critical thinking is essential for safe, effective midwifery practice. Understanding critical thinking in midwifery practice makes processes explicit. Three new tools are available to measure critical thinking in midwifery practice. A 4 phase conceptual model of critical thinking in midwifery practice is presented. The model can be used in practice and education to understand midwifery thinking.

Background:Certification as a lactation consultant is based on practitioners having achieved a standard of knowledge indicative of their competence to practice by passing a psychometric examination. The underpinning principle of recertification programs is to support clinicians to become lifelong learners by progressively enhancing and advancing their knowledge and skills in line with contemporary evidence. The aim of this study was to investigate the factors that influence International Board Certified Lactation Consultants (IBCLCs) to advance their practice.Method:A mixed-methods study was conducted in two phases. Phase 1 included focus groups, interviews, and participants’ demographic data. Phase 2 comprised of an online questionnaire to IBCLCs. This approach was designed to provide a comprehensive qualitative understanding of the IBCLCs’ experiences, which was then triangulated with quantitative data from a significantly larger population of IBCLCs in Phase 2.Results:The findings are described in themes and subthemes. Participants in phase 2 (n = 3,946) reported being intrinsically motivated (93.3%, n = 3,631) and committed to providing evidence-based guidance and optimal care to support breastfeeding mothers. They identified various sources of continuing education, although attendance at conferences, peer support, and reflective sessions were the most common approaches to enhancing knowledge. They recognized that it was through extension of knowledge that they were able to advance their practice.Conclusion:This article identifies strategies that the managers, educators, and certification bodies can adopt to support the IBCLCs in continuing to advance their practice, which will ultimately improve breastfeeding outcomes for mothers.

Test the concurrent validity of three newly developed tools (student self-rating, preceptor rating, and reflective writing) that aim to measure critical thinking in midwifery practice.A descriptive matched cohort design was used.Australian research intensive university offering a three year Bachelor of Midwifery programme.Fifty-five undergraduate midwifery students.Students assessed their ability to apply critical thinking in midwifery practice using a 25-item tool and a 5-item subscale in Motivated Strategies for Learning Questionnaire. Clinical preceptors completed a 24-item tool assessing the students' application of critical thinking in practice. Reflective writing by students was assessed by midwifery academics using a 15-item tool. Internal reliability, and concurrent validity were assessed. Correlations, t-tests, multiple regression and confidence levels were calculated for the three scales and associations with student characteristics.The three scales achieved good internal reliability with a Cronbach's alpha coefficient between 0.93 and 0.97. Matched total scores for the three critical thinking scales were moderately correlated; student/preceptor (r=0.36, p0.01); student/reflective writing (r=0.38, p0.01); preceptor/reflective writing (r=0.30, p0.05). All critical thinking mean scores were higher for students with a previous degree, but only significant for reflective writing (t (53)=-2.35, p=0.023). Preceptor ratings were predictive of GPA (beta=0.50, p0.001, CI=0.10 to 0.30). Students' self-rating scores were predictive of year level (beta=0.32, p0.05, CI=0.00 to 0.03).The student, preceptor, and reflective writing tools were found to be reliable and valid measures of critical thinking. The three tools can be used individually or in combination to provide students with various sources of feedback to improve their practice. The tools allow formative measurement of critical thinking over time. Further testing of the tools with larger, diverse samples is recommended.

Aim This study aimed to identify personal, professional and workplace factors that contribute to burnout in midwives. Background Burnout is prevalent in the midwifery workforce. Burnout adversely affects the well-being of midwives, diminishes the quality of care they provide and can shorten career duration. Design Self-administered online survey. The survey included the Copenhagen Burnout Inventory as well as personal and professional variables related to age, children, years of experience, role, model of care and satisfaction with work-life. Midwives were invited to participate via an email sent the Australian College of Midwives and through professional networks between June and July 2014. Variables associated with burnout were entered in a multinomial logistic regression. Results A total of 1037 responses were received and 990 analysed. The prevalence of moderate to severe personal (N=643 64.9%) and work-related burnout (N=428 43.8%) were high. Having children, providing caseload midwifery care and working in a regional area were associated with low burnout. However, midwives registered for 5-10 years were more likely to report work and client related burnout. Similarly, midwives reporting a lack of satisfaction with work-life balance were also more likely to report personal and work-related burnout. Conclusions Family-friendly work environments that facilitate work-life balance can help to reduce the personal and organisational costs of burnout. Similarly, providing continuity of midwifery care in a caseload model can facilitate work-life balance and provide significant mental health benefits to participating midwives. This article is protected by copyright. All rights reserved.

Problem or issue • Rates of elective and unplanned caesarean section continue to increase in high income countries. • Evidence-based clinical guidelines aim to promote and support normal birth but are rarely evaluated. What is already known The Queensland Normal Birth Guideline was developed in consultation with stakeholders and disseminated to public and private hospitals and released in 2012.1 Impact of the Guideline on practice has not been investigated. What this paper adds • Although most midwives (90%) were aware of the guideline, only 71% reported that it routinely guided practice. • Being employed in a public hospital caseload model, and having a strong belief in evidenced based practice predicted guideline use.

Background As a strategy to promote workforce sustainability a number of midwives working in one health district in New South Wales, Australia were trained to offer a reflective model of clinical supervision. The expectation was that these midwives would then be equipped to facilitate clinical supervision for their colleagues with the organisational aim of supporting professional development and promoting emotional well-being. Aim To identify understanding, uptake, perceptions of impact, and the experiences of midwives accessing clinical supervision. Method Mixed Methods. In phase one 225 midwives were invited to complete a self-administered survey. Descriptive and inferential statistics were used to analyse the data. In phase two 12 midwives were interviewed. Thematic analysis was used to deepen understanding of midwives’ experiences of receiving clinical supervision. Results Sixty percent of midwives responding in phase one had some experience of clinical supervision. Findings from both phases were complementary with midwives reporting a positive impact on their work, interpersonal skills, situational responses and career goals. Midwives described clinical supervision as a formal, structured and confidential space for ‘safe reflection’ that was valued as an opportunity for self-care. Barriers included misconceptions, perceived work related pressures and a sense that taking time out was unjustifiable. Conclusion Education, awareness raising and further research into reflective clinical supervision, to support emotional well-being and professional midwifery practice is needed. In addition, health organisations need to design, implement and evaluate strategies that support the embedding of clinical supervision within midwives’ clinical practice.

Objective Develop and test a tool designed for use by pre-registration midwifery students to self-appraise their critical thinking in practice. Design A descriptive cohort design was used. Participants All students (n=164) enrolled in a three-year Bachelor of Midwifery program in Queensland, Australia. Methods The staged model for tool development involved item generation, mapping draft items to critical thinking concepts and expert review to test content validity, pilot testing of the tool to a convenience sample of students, and psychometric testing. Students (n=126, 76.8% response rate) provided demographic details, completed the new tool, and five questions from the Motivated Strategies for Learning Questionnaire (MSLQ) via an online platform or paper version. Findings A high content validity index score of 0.97 was achieved through expert review. Construct validity via factor analysis revealed four factors: seeks information, reflects on practice, facilitates shared decision making, and evaluates practice. The mean total score for the tool was 124.98 (SD=12.58). Total and subscale scores correlated significantly. The scale achieved good internal reliability with a Cronbach's alpha coefficient of 0.92. Concurrent validity with the MSLQ subscale was 0.35 (p Conclusion This study established the reliability and validity of the CACTiM – student version for use by pre-registration midwifery students to self-assess critical thinking in practice. Implications for practice Critical thinking skills are vital for safe and effective midwifery practice. Students' assessment of their critical thinking development throughout their pre-registration programme makes these skills explicit, and could guide teaching innovation to address identified deficits. The availability of a reliable and valid tool assists research into the development of critical thinking in education and practice.

Background Reflective practice is considered an essential aspect of personal and professional development, and critical reflection is considered the cornerstone of being an accountable and autonomous practitioner. Tertiary education should lay the foundations of lifelong learning by ensuring students develop into critically reflective and reflexive practitioners, who demonstrate self-awareness and an ability to reflect on personal values and beliefs and their impact on the wider healthcare system. This level of reflective practice is essential to effect change at both an individual and societal level. Reflection should therefore be embedded into education programs as a learning, teaching and assessment strategy. Aim The aim of this paper is to describe a structured Model of Holistic Reflection embedded within an Australian Bachelor of Midwifery Program. The paper firstly outlines the theoretical and conceptual underpinnings of the newly developed model. Secondly describes the six integrated and inter-dependant phases of the model. Discussion and conclusion The aim of developing the Holistic Reflective Model was to produce a sound educational tool to assist midwifery students to progressively build reflexivity and reflective practice. Furthermore, provide midwifery academics with an educational resource to facilitate development of reflective and critical thinking skills in students. The specific intention was to promote deep personal and transformative learning across an entry to practice program. This paper highlights a number of ways the model can be embedded within the curriculum to support the scaffolded development of critical reflection and reflexivity required to facilitate transformative learning. While evaluation is required the model may have transferability to other disciplines.

Access to continuity of midwifery care (CoMC) models in Australia is increasing but the capacity of the emerging midwifery workforce to provide this care remains largely unknown. The aim of this integrative literature review is to discover how well pre-registration midwifery education prepares and motivates Australian midwifery students to work in CoMC models when they enter practice. Following title review of 432 papers, removal of duplicates and review against the inclusion and exclusion criteria, nine papers were included for review. The results show that access to CoMC is a crucial component of midwifery education, equipping students with knowledge, skills, confidence and motivation to work in this way upon graduation. Existing methods of program delivery and institutional structures often present students with challenges that detract from the value of their CoMC experiences. A focus on CoMC placement - particularly with a continuity of midwifery mentor - may motivate graduates to work in this model of care. This strategy is recommended to better align Australian midwifery education with maternity care reform.

Health professionals are required to reflect on practice to evaluate and improve care in rapidly changing health care environments. This study explored the professional development needs of educators facilitating development of reflective capacity in midwifery students using the Bass Model of Holistic Reflection. Thirteen midwifery academics at two Australian universities took part in the study conducted in three phases. Phase 1 identified the learning needs of educators described as 'understanding the building blocks of reflection'; 'practical application of the model, and 'assessment of reflective capacity'. Phase 2 involved an Intervention including development of a reflective practice tool kit and delivery of a two-day workshop. Phase 3 evaluated the experience of educators using the resources and four themes emerged: 1) 'Educators value a reflective practice toolkit'; 2) 'A toolkit builds confidence and trust in the model through promotion of deep personal reflection'; 3) 'Effective use of the model is key to achieving consistency in application by educators; and 4) 'Deeper understanding of the model promotes transformation of practice'. This paper confirms the importance of developing resources for educators, that support reflective pedagogy when implementing models of reflection into curricula.

Problem Caesarean section rates have risen in high-income countries. One of the potential drivers for this is the widespread use of CTG monitoring. Background Intrapartum cardiotocograph monitoring is considered to be indicated for women at risk for poor perinatal outcome. Aim This systematic literature review with meta-analysis examined randomised controlled trials and non-experimental research to determine whether cardiotocograph monitoring rather than intermittent auscultation during labour was associated with changes in perinatal mortality or cerebral palsy rates for high-risk women. Methods A systematic search for research published up to 2019 was conducted using PubMed, CINAHL, Cochrane, and Web of Science databases. Non-experimental and randomised controlled trial research in populations of women at risk which compared intrapartum cardiotocography with intermittent auscultation and reported on stillbirth, neonatal mortality, perinatal mortality and/or cerebral palsy were included. Relative risks were calculated from extracted data, and meta-analysis of randomised controlled trials was undertaken. Findings Nine randomised controlled trials and 26 non-experimental studies were included. Meta-analysis of pooled data from RCTs in mixed- and high-risk populations found no statistically significant differences in perinatal mortality rates. The majority of non-experimental research was at critical risk of bias and should not be relied on to inform practice. Cardiotocograph monitoring during preterm labour was associated with a higher incidence of cerebral palsy. Discussion Research evidence failed to demonstrate perinatal benefits from intrapartum cardiotocograph monitoring for women at risk for poor perinatal outcome. Conclusion There is an urgent need for well-designed research to consider whether intrapartum cardiotocograph monitoring provides benefits.

Background Reflective practice is a core professional competency and the hallmark of an autonomous, evidence-based midwife practitioner committed to lifelong learning. Despite this professional imperative little is currently known about how the development of reflective capacity is facilitated with midwifery students. Aim This study aimed to determine (1) the extent to which a holistic, structured model of reflection develops reflective capacity in midwifery students; and (2) their perceptions of learning and teaching strategies that build reflective capacity. Design A qualitative cross-sectional design involving focus groups and thematic analysis. Participants The Bass Model of Holistic Reflection was introduced to promote development of reflective capacity in midwifery students enrolled in entry to practice programs in two Australian universities. Students were provided with guidance on how to apply the model to their reflections. After using the model for at least one trimester twenty-seven (27) participants volunteered to participate in focus groups. Findings Four themes emerged ‘safe space within a circle of trust’, ‘deep personal learning’, ‘consistency of application by skilled facilitators’, and ‘integration and connection’. Key conclusions and implications for practice Use of a holistic model combined with integrative and structured reflective activities supports the scaffolded and developmental nature of reflection. Alignment of the model with a woman centred midwifery philosophy generates midwifery knowledge and reflects student expectations of their role as aspiring midwives. Midwives’ attitudes regarding reflection influences students’ perceptions of value. Quality of feedback provided by educators affects levels of student motivation and engagement with reflection.

PURPOSE: Ankyloglossia (commonly referred to as tongue-tie), is increasingly being reported as a significant contributory factor to difficulties experienced in establishing the mother–infant breastfeeding relationship. Frenotomy as a management option is contributing to international interest and interdisciplinary controversy. The aim of this article was to identify and examine the evidence in relation to frenotomy to inform practice for newborns diagnosed with symptomatic ankyloglossia.DESIGN: An integrated literature review, informed by Whittemore and Knafl (2005) was used to identify and evaluate contemporary evidence.MAJOR FINDINGS: There is a marked difference in opinion between health disciplines regarding frenotomy as a treatment option for ankyloglossia. There is agreement that support from a trained professional such as a lactation consultant prior to undergoing any invasive procedures to treat ankyloglossia is essential. Controversy persists however as to whether the condition will resolve spontaneously without treatment.CONCLUSION: Although frenotomy does seem to resolve breastfeeding difficulties, little is known regarding long-term consequences for the baby and optimal timing for the procedure. This review indicates a need for education of professionals and standardization of assessment processes along with ongoing research to identify efficacy and optimal timing of frenotomy when used.

Background Within the context of an ageing health workforce it is important to gain a greater understanding of the motivations of young people (aged less than 21 years) to choose a career in midwifery. Aim To explore the reasons why young students decided to study midwifery and enrol in one Australian Bachelor of Midwifery program. Method A descriptive exploratory qualitative design was used. Eleven midwifery students aged less than 21 years on enrollment participated in a semi-structured tape-recorded interview. The transcribed interviews were analysed using thematic analysis. Findings Direct and indirect exposure to positive constructions of childbirth as well as the midwives role fuelled young student's fascination with midwifery and drove their desire to enrol. While some young students entered midwifery studies as a result of their ‘love of babies’ others took a more pragmatic ‘wait and see’ approach about their career choice. Many young students however clearly distinguished midwifery from nursing demonstrating an intention to be a midwife rather than a nurse. This decision often took place within the context of opposition from within their family, school and social networks where the public discourse continued to reinforce nursing as the preferred pathway to midwifery. Conclusion Creating opportunities for young people to be exposed to positive constructions of childbirth as well as midwifery role models may increase the number of young students entering midwifery. There is also a need for information to be provided to school careers officers to assist them to understand the distinction between midwifery and nursing.

Background The value and importance of incorporating strategies that promote critical thinking in nursing and midwifery undergraduate programmes are well documented. However, relatively little is known about the effectiveness of teaching strategies in promoting CT. Evaluating effectiveness is important to promote ‘best practise’ in teaching. Objective To evaluate the efficacy of teaching methods used to develop critical thinking skills in nursing and midwifery undergraduate students. Data Sources The following six databases; CINAHL, Ovid Medline, ERIC, Informit, PsycINFO and Scopus were searched and resulted in the retrieval of 1315 papers. Review Methods After screening for inclusion, each paper was evaluated using the Critical Appraisal Skills Programme tool. Twenty-eight studies met the inclusion criteria and quality appraisal. Results Twelve different teaching interventions were tested in 8 countries. Results varied, with little consistency across studies using the same type of intervention or outcome tool. Sixteen tools were used to measure the efficacy of teaching in developing critical thinking. Seventeen studies identified a significant increase in critical thinking, while nine studies found no increases, and two found unexplained decreases in CT when using a similar educational intervention. Conclusions Whilst this review aimed to identify effective teaching strategies that promote and develop critical thinking, flaws in methodology and outcome measures contributed to inconsistent findings. The continued use of generalised CT tools is unlikely to help identify appropriate teaching methods that will improve CT abilities of midwifery and nursing students and prepare them for practise. The review was limited to empirical studies published in English that used measures of critical thinking with midwifery and nursing students. Discipline specific strategies and tools that measure students' abilities to apply CT in practise are needed.

Background There is growing body of evidence that suggests many midwives are unhappy and as a result are making decisions to leave the profession. Aim Determine the incidence of midwives indicating their intention to leave the profession and explore the reasons for this decision including what might cause midwives to be dissatisfied. Method Data analysed was collected as part of the Australian arm of the Work, Health and Emotional Life of Midwives (WHELM) project. Descriptive statistics and latent content analysis was used to analysis the data set. Results Almost half (42.8%, n = 443/1037) the midwives had considered leaving the profession in the preceding six months. The qualitative and quantitative data aligned with ‘dissatisfaction with the organisation of midwifery care’ and/or ‘dissatisfaction with my role as a midwife’ being the two commonest reasons behind the intention to leave. Early career midwives were most likely to consider leaving the profession (p = .05) due to dissatisfaction with their role. Almost half the midwives who had considered leaving the profession were most dissatisfied with managers (p = Conclusion Midwives felt their ability to provide quality maternity care was constrained by a fragmented medicalised system that did not work for the women in their care or themselves. The results of this study add to a growing call for policy makers and health care providers to reorientate maternity services to enable women to build positive longitudinal relationships with midwives. Not only will this improve maternal and neonatal outcomes but provide a satisfying and sustainable way for working for midwives.

Clinical supervision is a strategy supporting nurses, midwives and other healthcare professionals in the provision of quality healthcare. Clinical supervision involves regular, protected time for reflection. Adequately prepared supervisors are essential, however there is limited knowledge about education/training programs and even less about those that are not discipline-specific. This paper 1) describes an eight-day foundational program, Clinical Supervision for Role Development Training as situated within the Spurr Supervisor Training Model and, 2) presents the results from routinely collected evaluation data. Simple descriptive analysis and latent content analysis were used to analyse data from 226 participants who filled out a self-administered questionnaire. Participants reported increased knowledge (87.5%), skills (87%) and confidence to apply the techniques learnt (85.5%); 95% found practice sessions to be useful, and expectations of the training had been met. Qualitative data supported the positive quantitative results. The program was positively assessed by participants, irrespective of professional discipline. The pragmatic nature of the training and the safe learning environment was considered important to the development of skills and confidence as a supervisor. A more robust evaluation process and prospective, longitudinal research is needed to better understand the expectations and learning experience of participants, and implementation in the healthcare environment.

Objective develop and test a tool designed for use by preceptors/mentors to assess undergraduate midwifery students׳ critical thinking in practice. Design a descriptive cohort design was used. Setting participants worked in a range of maternity settings in Queensland, Australia. Participants 106 midwifery clinicians who had acted in the role of preceptor for undergraduate midwifery students. Methods this study followed a staged model for tool development recommended by DeVellis (2012). This included generation of items, content validity testing through mapping of draft items to critical thinking concepts and expert review, administration of items to a convenience sample of preceptors, and psychometric testing. A 24 item tool titled the XXXX Assessment of Critical Thinking in Midwifery (CACTiM) was completed by registered midwives in relation to students they had recently preceptored in the clinical environment. Findings ratings by experts revealed a content validity index score of 0.97, representing good content validity. An evaluation of construct validity through factor analysis generated three factors: ‘partnership in practice', ‘reflection on practice' and ‘practice improvements'. The scale demonstrated good internal reliability with a Cronbach alpha coefficient of 0.97. The mean total score for the CACTiM scale was 116.77 (SD=16.68) with a range of 60–144. Total and subscale scores correlated significantly. Conclusion the CACTiM (Preceptor/Mentor version) was found to be a valid and reliable tool for use by preceptors to assess critical thinking in undergraduate midwifery students. Implications for practice given the importance of critical thinking skills for midwifery practice, mapping and assessing critical thinking development in students׳ practice across an undergraduate programme is vital. The CACTiM (Preceptor/Mentor version) has utility for clinical education, research and practice. The tool can inform and guide preceptors׳ assessment of students׳ critical thinking in practice. The availability of a reliable and valid tool can be used to research the development of critical thinking in practice.

Background The Practice Environment Scale (PES) has been used extensively to measure the quality of the practice environment of nurses working in a variety of work settings, and has been linked with quality of care, nurse wellbeing, job dissatisfaction and burnout. Although developed for nurses, many of the aspects addressed by the PES are also relevant to the midwifery profession, and may provide a tool to better understand midwives' decision to leave the profession. Aim To adapt the PES for use with midwives and to assess its psychometric properties. Methods An online survey containing the adapted version of the PES was distributed to a sample of hospital-employed New Zealand midwives ( n =600). Exploratory factor analysis was conducted to identify subscales which were compared for midwives who had, versus had not considered, leaving the midwifery profession. Findings Four subscales were identified, showing good internal consistency reliability ( Quality of Management , Midwife–Doctor Relations, Resource Adequacy and Opportunities for Development ). The lowest mean score was recorded for Resource Adequacy ( M =2.38). All subscales of the adapted 20-item PES:Midwives were significant predictors of the decision to leave the profession ( p Quality of Management (OR=2.6). Conclusion The PES:Midwives was successfully adapted for use with midwives and provides a psychometrically sound tool for research to identify factors associated with the wellbeing, job satisfaction and risk of attrition amongst hospital employed midwives. The PES:Midwives also provides a means of comparing the practice environment across different models of care and employing organizations.

Background/Aims: A conservative estimate suggests women giving birth in Malawi are 14 times more likely to die giving birth than women in western nations. Despite attempts to address maternal and neonatal health, Malawi will not meet World Health Organization Millennium Development Goals 3, 4 and 5 for improving gender equity, reducing child mortality and improving maternal health by 2015. This integrative literature review looks through a social lens to view Malawi's progress towards meeting Millennium Development Goals 3, 4 and 5. Methods: A search was conducted using CINAHL, Google Scholar, Medline and Health Source online databases. Initial keywords included but were not limited to: gender bias; gender inequality; midwifery care; maternity; traditional birth attendants; skilled birth attendants; and social determinants. All searches included keywords with Boolean operator ‘and’ Malawi. Search filters were limited to publications dated from 2010 to 2015 and in English only. Additionally, reference lists from articles selected were reviewed, which led to further relevant sources. Although 48 articles were accessed, only 13 were considered to have high relevance, credibility and currency and were therefore included. Findings: Poverty underpins all social determinants of health and is the primary barrier to Malawi achieving the Millennium Development Goals. Poverty limits girls' access to education, which increases their risk of being exposed to infectious diseases. A lack of education is also associated with limited use of primary maternity care with a skilled birth attendant. Conclusions: Primary maternity care needs to be affordable and acceptable to Malawian women and provided close to their families and communities. The primary responsibility for this rests with Malawi's government, which should be encouraged to adopt supportive, enabling policies. To assist in this, western governments need to be socially responsible in deployment of their foreign aid and strategies to attract and retain skilled workers.

Objective to assess the psychometric properties of the Perceptions of Empowerment in Midwifery Scale (PEMS) on a sample of New Zealand midwives. Design cross sectional study. Midwives completed an online survey containing the 22 item PEMS, and a number of demographic and work-related questions. Participants active practising members listed on the New Zealand College of Midwives database were invited to participate. A sample of midwives who were currently employed by an organisation was extracted ( n =600). Findings exploratory factor analysis on the PEMS identified four subscales (Autonomy/Empowerment, Manager Support, Professional Support, Skills and Resources). This structure differed from that reported by the original scale developers. Each subscale showed adequate internal consistency reliability and was able to distinguish midwives who had considered leaving the profession in the past six months ( p =.001). Key conclusions the psychometric properties of the revised 19-item four-subscale structure of PEMS were supported. Implications for practice The PEMS-Revised provides a psychometrically sound tool for further quantitative research to supplement the growing number of qualitative investigations of midwives perceptions and experiences of their workplace.

Summary Background Well developed critical thinking skills are essential for nursing and midwifery practices. The development of students' higher-order cognitive abilities, such as critical thinking, is also well recognised in nursing and midwifery education. Measurement of critical thinking development is important to demonstrate change over time and effectiveness of teaching strategies. Objective To evaluate tools designed to measure critical thinking in nursing and midwifery undergraduate students. Data Sources The following six databases were searched and resulted in the retrieval of 1191 papers: CINAHL, Ovid Medline, ERIC, Informit, PsycINFO and Scopus. Review Methods After screening for inclusion, each paper was evaluated using the Critical Appraisal Skills Programme Tool. Thirty-four studies met the inclusion criteria and quality appraisal. Sixteen different tools that measure critical thinking were reviewed for reliability and validity and extent to which the domains of critical thinking were evident. Results Sixty percent of studies utilised one of four standardised commercially available measures of critical thinking. Reliability and validity were not consistently reported and there was a variation in reliability across studies that used the same measure. Of the remaining studies using different tools, there was also limited reporting of reliability making it difficult to assess internal consistency and potential applicability of measures across settings. Conclusions Discipline specific instruments to measure critical thinking in nursing and midwifery are required, specifically tools that measure the application of critical thinking to practise. Given that critical thinking development occurs over an extended period, measurement needs to be repeated and multiple methods of measurement used over time.

Background In 2010 Australian Government reform of maternity services enabled midwives to access Medicare. This significant change provides midwives with new opportunities to engage in patterns of working that provide continuity of care to childbearing women. There remains limited evidence, however, on midwives perceptions of how the reforms impact them both personally and professionally. Aim This research examined midwives’ perceptions of their role and how, in light of the reform agenda, they might conceptualise a change in working patterns and environment to provide greater levels of continuity of care. Method A qualitative descriptive approach was employed using the four-stage Appreciative Inquiry model. Twenty-three midwives from three maternity units within south-east Queensland participated in one of six focus groups. Thematic iterative analysis was employed to identify empirical codes and examine relationships within and across the data. Findings Midwives endorsed the reforms and considered the concept of continuity of midwifery care as fundamental to achieving a woman centred maternity system. Most participants, however, found it difficult to conceptualise how they might contribute to any level of system change. In addition the majority passively accepted the status quo of their employing organisation and believed they were powerless to effect change. Conclusion In order to promote the growth of evidence based continuity of care models midwives need to work to their full scope of practice. Strong midwifery leadership is required to enable midwives to re-conceptualise roles and work patterns and identify how they can engage with and contribute to reform of maternity services.

Background Practice-based or clinical placements are highly valued for linking theory to practice and enabling students to meet graduate outcomes and industry standards. Post-practicum, the period immediately following clinical experiences, is a time when students have an opportunity to share, compare and engage critically in considering how these experiences impact on their learning. Reflective practice has merit in facilitating this process. Aim This project aimed to optimise the learning potential of practice-based experiences by enhancing midwifery students’ capacity for reflective practice through writing. Methods Design-based research was used to implement an educational intervention aimed at developing reflective practice skills and enhance reflective writing. The Bass Model of Holistic Reflection was introduced to promote the development of reflective capacity in midwifery students. Academics and midwifery students were provided with guidance and resources on how to apply the model to guide reflective writing. Students’ written reflections completed before (n = 130) and after the introduction of the intervention (n = 96) were evaluated using a scoring framework designed to assess sequential development of reflective capacity. Findings The pre-intervention scores ranked poorly as evidence of reflective capacity. All scores improved post-intervention. Conclusions The introduction of a holistic structured model of reflection resulted in improved scores across all five components of reflective writing; self-awareness, sources of knowledge, reflection and critical reflection, evidence informed practice and critical thinking. While further work is required the results show that the implementation process and use of the Bass Model enables students to demonstrate their capacity to reflect-on-practice through their writing.

AIM: To examine the contribution of the Virtual International Day of the Midwife (VIDM) conference to midwives’ continuing professional development (CPD).BACKGROUND: Knowledge and understanding of CPD for midwives as synchronous online learning is limited. Studies of e-learning programs for CPD have underlined the need for interaction with others. The VIDM is a synchronous online 24-hour conference freely available for midwives designed to provide a unique CPD opportunity.METHOD: An online survey with a mix of fixed-response, multiple-response, and open-ended free-text questions was available to participants for 1 month after the conference via the wiki page in 2012 and 2013.FINDINGS: The survey was completed by 239 conference participants. Midwifery students and clinical midwives were the largest groups of attendees. The most common countries of residence were Australia, United Kingdom, and United States. Respondents believed that the conference contributed to their professional development by enabling professional growth, facilitating shared learning, and raising awareness of global issues.CONCLUSION: Offering synchronous events is important to facilitate deeper learning for those engaging in online activities. As an annual synchronous 24-hour, open online conference, the VIDM has become a valuable CPD opportunity for midwives.

Background developing a student׳s sense of capability, purpose, resourcefulness, identity and connectedness ( five-senses of success ) are key factors that may be important in predicting student satisfaction and progression within their university program. Aim the study aimed to examine the expectations and experiences of second and third year midwifery students enroled in a Bachelor of Midwifery program and identify barriers and enablers to success. Method a descriptive exploratory qualitative design was used. Fifty-six students enroled in either year 2 or 3 of the Bachelor of Midwifery program in SE Queensland participated in an anonymous survey using open-ended questions. In addition, 16 students participated in two year-level focus groups. Template analysis, using the Five Senses Framework, was used to analyse the data set. Findings early exposure to ‘hands on' clinical midwifery practice as well as continuity of care experiences provided students with an opportunity to link theory to practice and increased their perception of capability as they transitioned through the program. Student׳s sense of identity, purpose, resourcefulness, and capability was strongly influenced by the programs embedded meta-values, including a ‘woman centred' approach. In addition, a student׳s ability to form strong positive relationships with women, peers, lecturers and supportive clinicians was central to developing connections and ultimately a sense of success. A sense of connection not only fostered an ongoing belief that challenges could be overcome but that students׳ themselves could initiate or influence change. Conclusions the five senses framework provided a useful lens through which to analyse the student experience. Key factors to student satisfaction and retention within a Bachelor of Midwifery program include: a clearly articulated midwifery philosophy, strategies to promote student connectedness including the use of social media, and further development of clinician׳s skills in preceptorship, clinical teaching and facilitation. Program delivery methods and student support systems should be designed to enable maximum flexibility to promote capability and resourcefulness and embed sense of purpose and identity early in the program.

BACKGROUND: A shift has occurred in the last decade toward preregistration undergraduate Bachelor of Midwifery programs in Australia. This has led to an increase in the numbers of student midwives from diverse backgrounds with limited experience of university and socialization into hospital systems.AIM: This study aimed to explore commencing midwifery students’ beliefs about birth and expectations of the role of the midwife.METHOD: A qualitative descriptive approach was used. All 115 commencing first-year midwifery students enrolled in the first week of an undergraduate Bachelor of Midwifery program were invited and completed a self-administered survey. The survey used open-ended questions to elicit student beliefs about birth and the role of the midwife. Latent content analysis was used to analyze the data set.FINDINGS: Midwifery students’ beliefs were captured within the four themes: birth as “a miracle,” “a woman’s journey,” “a transformative event,” and “a natural process.” Students articulated the role of the midwife as one of support, education, advocacy, and partnership. Student beliefs and expectations were aligned with the emergent philosophy of the normality of birth and woman-centered care within the Australian maternity care context.CONCLUSION: Greater understanding is essential to designing quality midwifery education programs that are responsive to the needs of commencing student midwives. Supporting midwifery students’ successful transition into, and early engagement with the midwifery profession, may have long-term benefits in terms of retention and successful completion of their program. In addition, ensuring professional socialization occurs early is likely to develop graduates who are well prepared to work across their full scope and are willing to participate in the reform of maternity services in Australia.

Relatively little is known about the extent of trauma and birth-related fear in midwives and how this might affect practice.(1) Determine prevalence of birth related trauma and fear in midwives and associations with midwives' confidence to advise women during pregnancy of their birth options and to provide care in labour. (2) Describe midwives' experiences of birth related trauma and/or fear.A mixed methods design. A convenience sample of midwives (n=249) completed an anonymous online survey. Descriptive and inferential statistics were used to analyse the quantitative data. Latent content analysis was used to extrapolate meaning from the 170 midwives who wrote about their experiences of personal and/or professional trauma.The majority of midwives (93.6%) reported professional (n=199, 85.4%) and/or personal (n=97, 41.6%) traumatic birth experiences. Eight percent (n=20) reported being highly fearful of birth. Trauma was not associated with practice concerns but fear was. Midwives categorised as having 'high fear' reported more practice concerns (Med 23.5, n=20) than midwives with 'low fear' (Med 8, n=212) (U=1396, z=-3.79, p0.001, r=0.24). Reasons for personal trauma included experiencing assault, intervention and stillbirth. Professional trauma related to both witnessing and experiencing disrespectful care and subsequently feeling complicit in the provision of poor care. Feeling unsupported in the workplace and fearing litigation intensified trauma.High fear was associated with lower confidence to support childbearing women. Fear and trauma in midwives warrants further investigation to better understand the impact on professional practice.

develop and test a tool designed for use by academics to evaluate pre-registration midwifery students' critical thinking skills in reflective writing.a descriptive cohort design was used.a random sample (n = 100) of archived student reflective writings based on a clinical event or experience during 2014 and 2015.a staged model for tool development was used to develop a fifteen item scale involving item generation; mapping of draft items to critical thinking concepts and expert review to test content validity; inter-rater reliability testing; pilot testing of the tool on 100 reflective writings; and psychometric testing. Item scores were analysed for mean, range and standard deviation. Internal reliability, content and construct validity were assessed.expert review of the tool revealed a high content validity index score of 0.98. Using two independent raters to establish inter-rater reliability, good absolute agreement of 72% was achieved with a Kappa coefficient K = 0.43 (p0.0001). Construct validity via exploratory factor analysis revealed three factors: analyses context, reasoned inquiry, and self-evaluation. The mean total score for the tool was 50.48 (SD = 12.86). Total and subscale scores correlated significantly. The scale achieved good internal reliability with a Cronbach's alpha coefficient of .93.this study establishedthe reliability and validity of the CACTiM (reflection) for use by academics to evaluate midwifery students' critical thinking in reflective writing. Validation with large diverse samples is warranted.reflective practice is a key learning and teaching strategy in undergraduate Bachelor of Midwifery programmes and essential for safe, competent practice. There is the potential to enhance critical thinking development by assessingreflective writing with the CACTiM (reflection) tool to provide formative and summative feedback to students and inform teaching strategies.

Continuity of midwifery care contributes to significant positive outcomes for women and babies. There is a perception that providing continuity of care may negatively impact on the wellbeing and professional lives of midwives.To compare the emotional and professional wellbeing as well as satisfaction with time off and work-life balance of midwives providing continuity of care with midwives not providing continuity.Online survey. Measures included; Copenhagen Burnout Inventory (CBI); Depression, Anxiety and Stress Scale-21; and Perceptions of Empowerment in Midwifery Scale (PEMS-Revised). The sample (n=862) was divided into two groups; midwives working in continuity (n=214) and those not working in continuity (n=648). Mann Whitney U tests were used to compare the groups.The continuity group had significantly lower scores on each of the burnout subscales (CBI Personal p=.002; CBI Work p.001; CBI Client p.001) and Anxiety (p=.007) and Depression (p=.004) sub-scales. Midwives providing continuity reported significantly higher scores on the PEMs Autonomy/Empowerment subscale (p.001) and the Skills and Resources subscale (p=.002). There was no difference between the groups in terms of satisfaction with time off and work-life balance.Our results indicate that providing continuity of midwifery care is also beneficial for midwives. Conversely, midwives working in shift-based models providing fragmented care are at greater risk of psychological distress. Maternity service managers should feel confident that re-orientating care to align with the evidence is likely to improve workforce wellbeing and is a sustainable way forward.

Summary Background Midwives require well developed critical thinking to practice autonomously. However, multiple factors impinge on students' deep learning in the clinical context. Analysis of actual case scenarios using root cause analysis may foster students' critical thinking and application of ‘best practice' principles in complex clinical situations. Objective To examine the effectiveness of an innovative teaching strategy involving root cause analysis to develop students' perceptions of their critical thinking abilities. Methods A descriptive, mixed methods design was used. Final 3rd year undergraduate midwifery students ( n =22) worked in teams to complete and present an assessment item based on root cause analysis. The cases were adapted from coroners' reports. After graduation, 17 (77%) students evaluated the course using a standard university assessment tool. In addition 12 (54%) students provided specific feedback on the teaching strategy using a 16-item survey tool based on the domain concepts of Educational Acceptability, Educational Impact, and Preparation for Practice. Survey responses were on a 5-point Likert scale and analysed using descriptive statistics. Open-ended responses were analysed using content analysis. Results The majority of students perceived the course and this teaching strategy positively. The domain mean scores were high for Educational Acceptability (mean=4.3, SD=.49) and Educational Impact (mean=4.19, SD=.75) but slightly lower for Preparation for Practice (mean=3.7, SD=.77). Overall student responses to each item were positive with no item mean less than 3.42. Students found the root cause analysis challenging and time consuming but reported development of critical thinking skills about the complexity of practice, clinical governance and risk management principles. Conclusions Analysing complex real life clinical cases to determine a root cause enhanced midwifery students' perceptions of their critical thinking. Teaching and assessment strategies to promote critical thinking need to be made explicit to students in order to foster ongoing development.